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The Global Epidemiology, Public Health Outcomes, Management, and Prevention of Re-Emerging Ectoparasitic Diseases

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The Global Epidemiology, Public Health Outcomes, Management, and Prevention of Re-Emerging Ectoparasitic Diseases Tropical Medicine and Health Vol. 36 No. 1, 2008, pp. 1-10 Copyright! 2008 by The Japanese Society of Tropical Medicine １ Review The Global Epidemiology, Public Health Outcomes, Management, and Prevention of Re-Emerging Ectoparasitic Diseases James Herry. Diaz＊ Accepted 9 January, 2008 Abstract. The ancient ectoparasitic diseases share many features in common with newly emerging infectious dis- eases, such as Lyme disease, including hyperendemic causative agents afforded selective advantages by changing ecological or socioeconomic conditions; origination as zoonoses; transmission by competent arthropod vectors; and introduction into new, susceptible host populations. Many ectoparasites are also developing increased resis- tance to medical therapies, including the safest insecticides. Over the past two decades, there have been several re- ports of outbreaks of ectoparasitic diseases, principally myiasis, scabies, and tungiasis, both in regional communi- ties and in travelers returning from developing nations. Today ectoparasitic diseases infest not only executives and tourists returning from travel to developed and developing nations, but also individuals immunocompromised by advancing age and institutionalization, chronic infectious and malignant disease, malnutrition and homelessness. Ectoparasitic diseases are no longer infestations of children and socioeconomically disadvantaged populations in tropical countries; they have re-emerged as unusual, but not uncommon, infectious diseases worldwide. Key Words: Ectoparasites; Infestations, arthropod; Infectious diseases, emerging and re-emerging. ology of human ectoparasitic diseases in order to determine THE GLOBAL EPIDEMIOLOGY,PUBLIC HEALTH the factors responsible for their re-emergence and to de- OUTCOMES, AND PREVENTION OF RE-EMERGING velop effective strategies for the control and prevention of ECTOPARASITIC DISEASES community outbreaks. Today most areas of the world are accessible within 36 hours by commercial air travel [1]. As a result, interna- MATERIALS AND METHODS tional tourism to subtropical and tropical areas of both resource-poor and developed nations has tripled over the To chronologically evaluate the changing global epide- past two decades [1]. As national economies expand and miology of tropical ectoparasitic diseases and to determine personal incomes rise, there will be even more professional the human and environmental factors responsible for the re- time for business travel and more leisure time for vacation emergence of infectious ectoparasites with increased thera- travel to exotic locations, especially to regions with natural peutic resistance, data was extracted from both Medline attractions and pleasant climates. Several authors have now (National Library of Medicine) and Cochrane Review (The reported significant outbreaks of ectoparasitic diseases, Cochrane Collaboration, Oxford, UK) search engines, principally myiasis, scabies, and tungiasis in developing na- 1966-2007, of case reports, case series, descriptive epidemi- tions and in travelers returning from developing nations [1- ological investigations, analytical and pharmaceutical stud- 5]. In addition to these ectoparasitoses, the worldwide ies, and reviews of ectoparasitic diseases among both re- prevalence of other human ectoparasitic diseases is now in- gional populations and international travelers. creasing without regard to national economic development, including pediculosis, myiasis, and other flea, mite, and THE EPIDEMIOLOGY OF EMERGING INFECTIOUS DISEASES miscellaneous arthropod infestations, such as bed bugs [1, 6]. This review will examine the evolving global epidemi- With the exception of pediculosis and scabies, most *Corresponding author: Program in Environmental and Occupational Health Sciences, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana USA. 2021 Lakeshore Drive, New Orleans, LA 70122. Tel: 504-280-1600 Fax: 504-280-1516 E-mail: [email protected]. ２ human ectoparasitic diseases are caused by zoonotic dis- mens identified, there were 27 ticks, 24 flies, 15 miscellane- eases (e.g., myiasis, tungiasis), and most are arthropod- ous insects, and 7 mites [1]. Most of the arthropod derma- borne (pediculosis, scabies, myiasis, tungiasis). The most toses originated in the UK (n = 46, 63%), and were caused commonly encountered arthropod ectoparasitoses and their by tick bites (n = 18), principally Ixodes ricinus (the com- clinical manifestations are featured in Table 1. mon sheep tick), an important European vector of Lyme Ectoparasitic diseases share many of the characteristics disease and neuroborreliosis [1]. Myiasis cases predomi- of currently emerging infectious diseases, such as Lyme dis- nated in returning travelers (n = 18, 67%), principally fu- ease and West Nile virus, and even re-emerging infectious runcular myiasis from larval infestation by Cordylobia an- diseases, such as leptospirosis and tularemia [7, 8]. Com- thropophaga (n = 9), the Tumbu fly, or Dermatobia hominis monly shared characteristics of both ectoparisitoses and (n = 4), the human botfly [1]. Among the arthropod derma- emerging infectious diseases include: (1) origination as toses caused by miscellaneous insects, most were due to zoonoses with disease establishment dependent on insect pediculosis pubis caused by infestation with Phthirus pubis, vector competency; (2) introduction into new, susceptible the pubic louse (n = 7), or to hemorrhagic, bullous bite host populations; (3) infection by endemic agents afforded groupings caused by Cimex lectularius, the common bed- selective advantages by changing ecological and socioeco- bug (n = 3) [1]. Among bedbug bite cases, there were 2 in- nomic conditions; and (4) movement from rural to urban digenous cases, and 1 case in a traveler returning from Italy endemic areas, usually following migrating human host [1]. The authors concluded that exotic infestations, particu- populations seeking better economic opportunities [7, 8]. larly myiasis, predominated in returning travelers from Af- Ectoparasitic diseases also share several specific eti- rica and Latin America, while pubic lice were domestic in- ological emergence factors with both emerging and re- festations, and bed bug infestations were both domestically emerging infectious diseases including: (1) the influence of and internationally acquired [1]. human behavior on subsequent infections; (2) the effect of Recent epidemiological evidence now supports the en- parasite genetic adaptation and change on therapeutic drug demicity of several ectoparasitic diseases and their arthro- resistance; (3) the impact of international travel and the pod vectors and human and animal reservoir hosts through- globalization of trade and commerce on disease dissemina- out the developing world and in many parts of the devel- tion; (4) the breakdown of local public health infrastruc- oped world, including Europe. Ectoparasitic diseases have tures; and (5) the increasing urbanization of the world’s also re-emerged in regions where they were once effectively population with more inner city crowding in low-income controlled, such as in Belize, Mexico, and the Caribbean. housing [7-9]. Some recent specific examples of emergence Ectoparasitic diseases will continue to re-emerge in the de- factors shared by ectoparasitic diseases and emerging infec- veloped world for several reasons including (1) the globali- tious diseases include: (1) promiscuous sexual behavior zation of trade and commerce with ectoparasites and even spreading the sexually transmitted ectoparasitic diseases, their rodent hosts traveling worldwide on container ships scabies and pubic lice, or pediculosis pubis; (2) microbial and cargo airplanes; (2) the worldwide legitimate and illegal adaptations resulting in multi-insecticide resistant Pediculus trade of exotic animals; (3) the accidental and intentional humanus capitis (head lice); (3) furuncular myiasis in trav- introduction of exotic animal species into new regions; and elers returning from tropical vacations, and (4) a resurgence (4) the growing populations of accessible, and, often im- of scabies and tungiasis in both developing and developed munocompromised human hosts, living in crowded urban nations with languishing public health infrastructures, par- communities and mega-cities [6-10]. ticularly stray domestic animal and rodent control programs. THE EPIDEMIOLOGY AND PUBLIC HEALTH THE EPIDEMIOLOGY OF RE-EMERGING OUTCOMES OF SPECIFIC RE-EMERGING ECTOPARASITIC DISEASES ECTOPARASITIC DISEASES To assess the potential combined impact of increasing Pediculosis Pediculosis is a complex of three different hu- international travel and the relaxation of quarantine regula- man infestations with two species of blood-sucking lice of tions for imported animals in the United Kingdom (UK) on the insect suborder Anoplura, Pediculus humanus and arthropod-induced dermatoses, McGarry and colleagues de- Phthirus pubis. After early man began to wear clothes, scribed their analyses of 73 insect specimens removed from Pediculus humanus evolved into two clinically distinct ec- symptomatic patients and submitted to their laboratory for toparasitic variants, P. humanus corporis, the body louse, expert identification at the Liverpool School of Tropical and P. humanis capitis, the head louse. Although morpho- Medicine, during the years 1994-2000 [1]. Of the 73 speci- logically indistinct, these human lice variants do not inter- ３ breed and prefer unique anatomic niches on their human
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